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Trauma-Informed JJ
Moving Stories & Practical Strategies/Techniques For Youth with Brain-based Disorders
Jim Henry, PhD, MSW Mark A. Sloane, DOWestern Michigan University
Kalamazoo, MI31 March 2015
Why are you here this morning?
A)They had to drag me here!
B) I will sit here, but am cynical so I will dismiss what you have to say.
C)I am willing to listen… depending on what you say
D)I am a dreamer and know I can do something different
How do we engage you today?
Magic tricks
Whoever stays until the end wins beer
You learn more about yourself
You learn more about the kids and families you serve
Traditional Paradigm
Crime/Diagnostic -Focused
Willful Behavior
Trauma-Informed
Impact-Focused
Brain-Behavior based
Service -Driven Resiliency-focused Worker Resiliency
EventTraumatic
Impact
It’s time to meet Paul
The Real Game of Life:JJ Version
Prenatal Exposure to Alcohol and Drugs;Maternal Stress
Infancy: Unresponsive CaregiverInsecure attachment
Toddler: Physical Maltreatment
Emotionally dysregulated and Aggressive Child Behavior
Behavior problems at school; grade retention/ Suspensions
Child as BullyChild being Bullied
Child: DSM LabelODD, RAD, Bipolar
Entering Juvenile Justice System
Attention deficits at school Falling behind in school
Detention/ Residential placement
16 year-old teen male with long history of trauma and residential placement
“I can’t look forward to nothing because I can’t do anything about it.”
“I stay in a mellow state of nothing. I don’t feel nothing.”
“If I think about my life, it would drive me crazy.
I consider treatment as a punishment and I distrust others because they have not been honest with me.”
Reviewing CTAC Assessment Data for 35 youth in residential and detention
Residential Youth: Age Distribution
Residential: Frequencies of Race
Residential: Frequencies by Gender
Vocabulary Matrices Composite
Community Placement
89.75 93.92 91.13
Residential 88.23 87.83 86.11
Total 89.65 93.52 90.80
K-BIT 2 Results Per Residential Status
ADHD-RS Results Per Living Arrangement
Hyperactive-Impulsive
Inattentive Total
Community Placement T=72.95 76.84 76.39
Residential T=83.96 81.15 85.42
Sensory Profile Results: Children in Residential
% %
Tactile 29% 16%
Taste/Smell 6% 3%
Movement 10% 7%
Under-responsive
3% 26%
Auditory Filtering
20% 48%
Low Energy/Weak
3% 19%
Visual/Auditory
13% 6%
Total 11% 21%
ProbableDifference
Definite Difference
CBCL Results: Residential vs Community Placement
Anxious/Depressed
Withdrawn/Depressed
Somatic Complaints
SocialProblems
Thought Problems
Attention Problems
Rule-BreakingBehavior
Aggressive Behavior
InternalizingBehavior
ExternalizingBehavior
Total
Community Placement 60.38 62.83 58.28 63.17 63.5 66.51 64.70 66.84 60.75 65.06 65.11
Residential 61.83 63.07 56.00 64.07 63.5 67.55 66.28 68.10 61.97 67.73 67.37
Hyter Pragmatic Protocol Results: Children in Residential
%
Conversational Skills 39%
Story Retelling 59%
Story Generation 74%
One-Person Perspective 10%
Two-Person Perspective 60%
Three-Person Perspective 70%
Non-Literal Statements 60%
Demonstrated Difficulty
Percent that “Demonstrated Difficulty”
Hyter Pragmatic Protocol Results Per Residential Status
PEERAMID 2 Results: Residential and Community Placements
PEERAMID 2 Results: Residential and Community Placements
PEERAMID 2 Results: Residential and Community Placements (Continued)
PEERAMID 2 Results: Residential and Community Placements
PEERAMID 2 Results: Residential and Community Placements
PEERAMID 2 Results: Residential and Community Placements
DSM-IV Diagnoses for Children in Residential
Number of types of maltreatment experienced (out of 14, including natural disaster, community violence, etc. from Core Data Set)
Maltreatment Types based on Living Arrangement
What questions do these data raise?
Key Questions for JJ re placement options/decisions?
How can we explain the neurobehavioral similarities between residential and community placement youth?
Do the significant neurodevelopmental differences in expressive language, sequencing, attention, and memory (i.e. executive function) contribute to residential placement decisions?
How should residential treatment address the ND differences described above?
The Response:
Two Judicial Realities
The JJ Challenge
… “All too often the convenient decision is wrapped in a package as the right one”…
Judge Hofmann (Texas Child Protection Court) 2013
Hon. Michael NyeHillsdale(MI) Probate Judge (retired)
So…How do we get this done in Alaska???
It all starts with Trauma Screening & Neurodevelopmental Trauma Assessment
The JJ Story of “Chuck”
A Difficult to Believe Story
The Call from the Judge
“He used a sink as a weapon”
“We cant afford $414/day”
“Can you see him?”
More Sordid Details (re 16 y/o Chuck)
Entered residential from psychiatric facility at age 10 7 residential / detention stays over 6 years 15 medication trials (then only on Seroquel for sleep) Bipolar and Conduct Disorder Dx at 2 years of age! All the aggression took place at Mom’s or inside the walls Staff betrayal common occurrence
Neurodevelopmental Trauma Assessment
First impressions of Chuck…Hey wait a minute… Verbal IQ 84, Non-Verbal 94WRAT-4: Reading 100, Spelling 126, Math 117Major ND concerns: Expressive & Receptive Language,
Memory, Executive Function (not Hyperactive)
Neurodevelopmental Trauma Assessment
Trauma Symptom Checklist: Elevated scores: Anger, Dissociation
Psychosocial Interview: Prenatal stress, multiple losses, chronic anger, cycle of trauma suspected (later confirmed), chronic complex trauma, trust issues, worsening cycle of targeting by fellow “inmates, “in lock-up for 6 years”
Trauma-informed Diagnostic Formulation
Institutionalization(6 years) exacerbates early traumaContinuous Fight-Flight survival mode Hope was dependent on getting out Resiliency factors were significant:
Self-Efficacy (IQ, survival inside the walls, planned med wean)Relatedness (network of +/- relationships)History of reasonably solid regulation in the community
Trauma-informedNext Steps
“We have to get him out of there”
Security camera provides a way out
Judge takes a courageous stand
Trauma-informed, Resiliency-BasedCase Planning
Customized trauma-informed MST Brain-based / trauma-informed medication treatment Family placement / ongoing family psycho-education Trauma-informed probationMonthly consultation visits with MAS
The Next Chapter:Chuck’s Life Outside
Family placement: less than optimal Toxic relationship with mom leads to Pine Rest The STATE SPEAKS: “He had his chance”… STATE takes a stand… Judge takes over…
The Birthday Tale…
Saying goodbye to Aunt Sadie... 17 years old and free as a bird Day in court is memorable 10 months out…a work in progress Every day brings more hope…
Trauma-informed Takeaways
Neurodevelopmental trauma assessment provides information that looks at the context, the environment, and resiliency factors
Realistic optimism trumps cynicism Advocacy demands risk & challenges convenienceCommitment by the Team to build resiliency Brain-behavior-based practice is essential and
transforming
Building a Brain-Based
Trauma-Informed FASD-informed
TransformationalSystem for JJ
WELLBEING
FUTURE
HARM
BRAIN
SOLUTIONS
BEHAVIOR
STS
A Vision for JJ
WELLBEING
FUTURE
HARM
BRAIN
SOLUTIONS
BEHAVIOR
STS
A Vision for JJ
Challenging behavior in JJ
Why vs How
Trauma explains residential conundrums
WELLBEING
FUTURE
HARM
BRAIN
SOLUTIONS
BEHAVIOR
STS
A Brain-Behavior Vision for JJ
Brain – Behavior Functional Model:Step by Step JJ Explanations
Neurodevelopmental Core Base(IQ, Language, Learning Style, Attachment potential, etc)
Brakes vs Accelerator
Complex Affect Regulation
Behavioral Choice / Free Will
Social Communication
Sensory Processing / MSI
Brain – Behavior Functional Model:Step by Step JJ Explanations
Neurodevelopmental Core Base(IQ, Language, Learning Style, Attachment potential, etc)
Brakes vs Accelerator
Complex Affect Regulation
Behavioral Choice / Free Will
Social Communication
Sensory Processing / MSI
Brakes vs Accelerator Delicate Balance of Regulation:
Top-Down “Brakes” (Prefrontal Cortex)
Bottom-Up “Accelerator” (Brainstem/Limbic System)
Brakes (Upstairs)
Accelerator(Downstairs)
Bored / Low energy / Tired & sleepy (Ee-yore)
Opt
imal
“G
oldi
lock
s”A
rous
al
Way too wound-up / “wild” (“Tigger - on crack”)
Accelerator vs Brakes: Real World JJ Impact
Too wound-up (Tigger)
Total shut-down (via parasympathetics) “Ee-yore on Quaaludes”
“Goldilocks” Comfort Zone“Just Right” Energy Level
Brake-Accelerator FunctioningJJ Correlates / Realities
Accelerator Issues: in Panic / Worry
Trauma Triggers
in Anger / Explosiveness
in Mania / Hypomania
in Depression
in Drug Craving
Drug withdrawal:
Meth / Opiates
Brakes Issues working memory Impulse control
Critical skill when craving drugs
Genetic ADHD issues
Trauma impact
FASD impact
Drug impact (over time)
Brain – Behavior Functional Model:Step by Step JJ Explanations
Neurodevelopmental Core Base(IQ, Language, Learning Style, Attachment potential, etc)
Brakes vs Accelerator
Complex Affect Regulation
Behavioral Choice / Free Will
Social Communication
Sensory Processing / MSI
Hyter Model (2012) of Social Communication (Sloane Revision)
WorkingMemory
Social Cognition
ComplexAffect
Regulation
Language/PragmaticLanguage
Hyter-Sloane Model (2013) of Social Communication
WorkingMemory
Social Cognition
ComplexAffect
Regulation
Language/PragmaticLanguage
All components are impacted by prenatal alcohol exposure
and traumatic stress
Brain – Behavior Functional Model:Step by Step JJ Explanations
Neurodevelopmental Core Base(IQ, Language, Learning Style, Attachment potential, etc)
Brakes vs Accelerator
Complex Affect Regulation
Behavioral Choice / Free Will
Social Communication
Sensory Processing / MSI
What about behavior / choice / free will / willfulness ??
Don’t Forget About the Steering
Final JJ Brain-Behavior Thoughts: Regulation & Willfulness:
Power Steering vs Manual Steering
Regulated steering = power steering! Easier to make appropriate motor / behavioral / emotional decisions
while regulated
Dysregulated steering = manual steering Tougher to keep the behavioral “car” on the road
WELLBEING
FUTURE
HARM
BRAIN
SOLUTIONS
BEHAVIOR
STS
A Vision for JJ
The Brain-Behavior JJ connection: Seamless mesh of all 3 components
Genetics / EpigeneticsWhat you inherit from both parents
Intrauterine environment During pregnancy
Extrauterine environment After pregnancy
Combined impact on neurodevelopment:The CTAC “attributional stress” experience
CTAC: evaluated 3200+ children since Feb 2000
37 % of our traumatized child welfare sample (6-15 y/o) have been diagnosed with FASD
CTAC first to describe additive impact of trauma + FASD on neurodevelopment (Henry, Sloane, & Black-Pond 2007)
CTAC has not had much experience with non-traumatized FASD children This FASD population: a critical research question
The Brain-Behavior Connection:Complexities & Realities
Genetics / Epigenetics
Neurodevelopmental strengths / weaknesses Temperament / Personality Family history of:
Attentional disorders (ADHD)Learning disorders (e.g., Dyslexia)Mood disorders (Depression / Bipolar)Anxiety DisordersNeuropsychiatric disorders (Tourette Disorder)
Behavioral Epigenetics:The future is now!
Epigenetics: chemical alterations to DNA after conception
Epigenetics is the ultimate link between nature & nature
Increasing evidence that these epigenetic alterations may be passed on to the next generation
Can we assess this in the JJ setting?
The Brain-Behavior Connection:Complexities & Realities
Intrauterine environment
Exposure to drugs (legal / illegal)
Maternal stress
Maternal nutrition
Exposure to alcohol
The Brain-Behavior Connection:Complexities & Realities
Intrauterine Drug Exposure:The “Myth” of Meth (& crack / cocaine)
“Mixing and matching” drugs while pregnant
Multiple drug use in pregnancy overwhelms even ultra-fast research computers!
Nicotine use increases ADHD risk 4-fold
Cannabis use in pregnancy remains a bit controversial
The need for animal models to clarifyOpiate use during pregnancy (Neonatal Abstinence Syndrome)
The Brain-Behavior Connection:Complexities & Realities
Chronic and Severe Prenatal Stress:Growing appreciation of negative impact on fetus
What level of stress is damaging to fetus?
Placenta buffers mild-mod. stress: protects fetus
By 12 weeks gestation, the limbic system and PFC are susceptible
to chronic toxic stress (via cortisol)
Prenatal stress can lower birth weight
Prenatal stress can impact adult health (think ACES)
Solid early life parenting / attachment can be protective
(and can reverse some negative impact)
Influence of Prenatal Alcohol Exposure
FAS: not the whole storyFetal Alcohol Spectrum Disorders (FASD)
Fetal Alcohol Syndrome
Partial FAS
Alcohol-related Neurodevelopmental Disorder (ARND) (“mild-moderate” FAS)
Neurobehavioral Disorder –Associated with Prenatal Alcohol Exposure (DSM-5)
Adapted from Streissguth
ND-PAE: Neurobehavioral Disorder-associated with Prenatal Alcohol Exposure
Now appearing in DSM-5! (“Condition for further study”)
De-emphasis on FAS facial featuresFunctional impairment is key:
NeurocognitiveSelf-RegulationAdaptive behavior
History of Prenatal alcohol: critical pieceAAP FASD/ND-PAE Workgroup project
Fetal Alcohol Spectrum Disorder:Clinical Pearls of Wisdom
“Mild – Moderate” FASD is still very problematic
It is all about when the drinking occurred (during the pregnancy) and how much alcohol was consumed per session
Maternal blood alcohol level = fetal blood alcohol
Meth-Alcohol link: “Swiss cheese brain” issues
Confusion over why all fetal ETOH exposure is not created equal (SES / trauma risk factors)
Smooth philtrum Thin upper lip
Palpebral fissure (small eyes)
FASD: Critical Facial Abnormalities
Fetal Alcohol Syndrome:It doesn’t always look like this
…It can look like this!…clinical examples of FAS: transcending race
Severe brain damage caused by prenatal alcohol exposure
photo: Clarren, 19865-day old infants
Severe FAS
Normal Brain
Corpus Callosum
100 million neurons!!!
Connects the two brain hemispheres
Allows the left side to communicate with the right side
Assists the individual child to calm down during / after “meltdown”
Is often damaged/altered by prenatal alcohol exposure / traumatic stress
Corpus Callosum
Gross structural abnormalities in FAS(12 year old male subjects)
Normal Development Fetal Alcohol Syndrome
84
85
Star Trek Medicine: Diffusion Tensor Imaging
Child Traumatic Stress & the Developing Brain
“Trauma Trumps Everything”Sandra Bloom, MD
Trauma – Substance Abuse connection Trauma – Mental Health connection Trauma – Juvenile Justice connection Trauma – School failure connection
Cycle of trauma is pervasive… but can be addressed, treated, & prevented
Types of Stress National Scientific Council on the Developing Child (2005)
Traumatic Stress & the Child’s Developing Brain
Early and ongoing childhood toxic traumatic stress to the developing brain results in: Physical neuroplastic brain changes that :
Cause abnormal functioning (including memory)Contribute to problematic behaviors Contribute to developmental delaysResult in child being unable to realize potential
Neglect: The Worst Offender
Toxic Traumatic Stress & the Child’s Developing Brain
Research reveals a strong link between all types of childabuse /neglect and the subsequent development of psychiatric illness in adulthood
Key findings (ACES) link child traumatic stress with variety of child/adult medical illness
VJ Felitti, MD
Adverse Childhood Experiences Study (ACES)Pyramid of Doom!
Felitti et al. 1998;
How does ACES happen?
Traumatic Stress and the Brain
Stress and the tigerOur bodies are designed to respond to stress
Adrenalin and cortisol help us run from tiger or hide Threat of short duration
BUT…when the tiger lives in your home, neighborhood, or life…
Impact of chronic toxic stress on immune system function
…The developing Fight-Flight-Freeze system is chronically pressed into action:
Too much cortisol suppresses immune system, increasing risk of infection
Inflammatory response persists after it is no longer needed
Physical impact of trauma
Physical health effects on childrenSomatic perception gets impaired
Headache, stomachache
Elevated cortisol impacts inflammationAsthma – inflammatory component
Metabolic syndrome – obesity, insulin resistance, diabetes, cardiovascular disease
Cancer risk elevated
Infection fighting function impairedHigher risk of infection
Autoimmune disorders
Tracking the Physical Impact:The Telomere Story
DNA link to aging, illness, trauma
Exciting new development Imprint of your life journey on your DNACritical trauma link for:
PrenatalInfantsChildrenAdolescentsAdults (including caregivers / professionals)
The Telomere Story
The Telomere Story
Aging shortens telomeres leading to general breakdown of multiple body systems
Trauma also shortens telomeres
Does trauma healing lengthen telomeres?
Role of telomerase in this dynamic process
Resiliency
Resiliency contextualizes a child’s/adults strengths (individual, familial, community) against her/his adverse experiences
(Zolkoski & Bullock, 2012)
Traumatic Event/Events
Resiliency Factors
Traumatic Impact
Resiliency Factors (Masten, 2014; Southwick & Charney, 2012)
Effective caregiving and parenting qualityClose relationships with other capable adultsClose friends and romantic partners Intelligence and problem solving skills Self control, emotional regulation, planfulnessMotivation to succeed Self Efficacy Faith, hope, belief that life has meaning
Do you have what it takes to be a boxing coach?
Empathy is the foundation of relationship and relatedness.
“The ability to understand cognitively and affectively what someone else is going through.” “I can see the world from their perspective.”
What did the boxing coaches teach us about resiliency?
Established that the youth had personal value (foundation of relatedness) “I have no idea what you have been through, but I believe you
can be successful. “I don’t expect you to trust me. I will be honest with you.
Hopefully with time you can come to believe that.” “Somebody believes in me, even when I don’t there is anything
worth caring about”
What did the boxing coaches teach us about resiliency?
Believed in the youth that they could succeed (mastery/competency) Experiencing success changes usMotivation is dependent on being successful at some point Failure is a reality for everyone. How we handle failure determines
whether we are successful. We are not cheerleaders, we are not naysayers, we see the
potential in kids and build on that.
What did the boxing coaches teach us about resiliency?
Help him/her to regulate with the physical controlled release of emotion (affect regulation)Our kids do not have the skills of regulation. It is not anger
management it is emotional regulation. To learn regulation it must be modeled for you You must practice the skill so it can wire into the brain.
Traumatic Event/Events
Resiliency Factors
Traumatic Impact
AffectRegulationRelatedness Mastery
Strong
Good enough
Some
None
AffectRegulation
Relatedness
Kid Profile
Mastery
Strong
Good enough
Some
None
Our work affects us despite what we tell ourselves?
Have you ever felt like this?
Secondary Traumatic Stress
“The natural and consequent behaviors and emotions resulting from knowing about a painful event from a significant other, the stress from helping or wanting to help a stressed person, especially a child.”
Figley, 1995; Henry, 2012
Impact of STS on Staff
Cognitive effects
•Negative bias, pessimism•All-or-nothing thinking•Loss of perspective and
critical thinking skills•Threat focus – see clients,
peers, supervisor as enemy
•Decreased self-monitoring
Social impact
•Reduction in collaboration
•Withdrawal and loss of social support
•Factionalism
Emotional impact
•Helplessness•Hopelessness•Feeling overwhelmed
Physical impact
•Headaches•Tense muscles•Stomachaches•Fatigue/sleep difficulties